A practice in the Warrington area

7. Miss W complains about the service provided by the Practice to her late father in May 2024. Miss W complains that the Practice did not correctly diagnose her father’s chest complaint correctly, diagnosing him as having a chest infection rather than heart failure. Additionally, Miss W believes the Practice failed to recognise the signs of a deteriorating patient.

8. Miss W advises that a correct diagnosis would have led her father to be referred to hospital and could have prevented his death.

9. Miss W would like the Practice to apologise for how it treated her father. She would like it to improve its systems to ensure cardiac (heart) illnesses are accurately diagnosed. She is also seeking financial remedy to be provided in response to this avoidable death.

10. Mr W has a history of angina since December 2023 and had been treated by both the Practice and a local Trust, who are not party to this investigation.

11. In the week leading up to May 2024, Mr W had reported being woken up in the night by chest pain and pain in his arm. Mr W reported had to use his GTN spray (medication to treat angina) to alleviate it. He also noted a cough with phlegm alongside this.

12. At the start of May 2024 Mr W submitted an eConsult (a message through the Practice website) to his Practice detailing his symptoms. Mr W had a telephone appointment the same day.

13. Following the telephone appointment, Mr W attended the Practice in person the following day, where the Practice assessed him and diagnosed Mr W with a chest infection. Mr W was sent home with antibiotics, steroid medication and advice on what to do if the matter worsened.

14. Sadly, two days later Mr W was found dead at home by his family. Understandably, this must have been very traumatic for Mis W.

15. Two weeks later a post-mortem was undertaken. This conclude the cause of Mr W’s death was acute left ventricular failure, contributed to by ischaemic heart disease and hypertensive heart disease. This is a variation on what a layperson would call a heart attack.

19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong. We know this may be upsetting for Miss W and Mr W’s wider family. We hope our investigation provides some resolution for the family by showing that there is no indication that further action by the Practice could have changed the sad outcome of this matter.

20. We considered the Practice’s actions after Mr W’s initial contact at the start of May 2024. The practice uses an online system called eConsult. This is where patients with urgent concerns can submit a summary to the practice, via its website, between 5am and 12pm. Patients who use eConsult are guaranteed a same-day telephone appointment.

21. Mr W submitted an eConsult at 10.47am detailing his chest pain and was offered an afternoon telephone appointment that same day. We do see this as prompt and effective service and in line with the Practice’s promised procedure.

22. We then considered the telephone consultation. From the notes provided by the Practice, it appears this discussion was a reiteration of the detail identified in the eConsult, that Mr W suffered chest pain with the added mention of a cough that brought up phlegm.

23. The notes show the Practice offered Mr W a face to face appointment that same day. Sadly, Mr W was unable to attend due to lack of transport. An alternative, face to face appointment was then arranged for the following day. As we do not have any evidence to the contrary or an independent method of verifying what was said on this call, we are obliged to accept these records as fact.

24. We sought advice from our independent GP adviser (our adviser) to better understand if the Practice should have done more given Mr W’s medical history. Our adviser noted that there are no recommendations, either in the August 2022 NICE clinical knowledge summary or in general NHS guidance, to diagnose chest pain over a telephone appointment. These diagnoses should only be made face to face, and we note the Practice made all reasonable efforts to do so as soon as possible.

25. We appreciate that the Practice have acknowledged that its notetaking of the telephone consultation could be improved. This would have given a deeper level of detail about the issue to the person conducting the face to face appointment. We cannot, however, say that there are any indications of failing in how the telephone appointment was conducted.

26. In order to assess the face to face appointment we have considered the clinical records, the response letter from the Practice and sought our adviser’s position on the same. Our adviser has directed us towards the NICE CG95 guidance on assessing chest pain and the clinical knowledge summary (CKS) on chest infections.

27. Our adviser said if a patient attends a Practice with chest pain, it may be appropriate for the GP to immediately refer them to emergency care. However, our adviser also notes that the records and the Practice’s position in the response letter of 30 August 2024, show that the issue may be more nuanced than first appears.

28. A starting point is that the Practice note Mr W informed them via the telephone appointment that he had a cough that brought up phlegm. It is identified in the NICE CKS, that a productive cough (coughing up phlegm), along with some forms of chest pain could be a sign of a chest infection.

29. The documents provided by the Practice also show in the records that Mr W identified the pain as ebbing and flowing (coming and going), and did not worsen after physical movement around the surgery as directed by the GP.

30. The GP also states that Mr W’s breathing did not notably change at this time, and whilst his blood pressure was higher than normal, it was not so high to raise any concern. The NICE CKS on chest infections does show that these are symptoms that are indicative of chest infections and so it does appear that the Practice diagnosis and treatment option were reasonable.

31. What should be considered is Mr W’s history of angina. We sought the input of our adviser who directed us to the NICE CG95 guidance, section 1.3.3.1 which states anginal pain can only be considered if,

• the patient has constricting pain in the chest, neck shoulders jaws or arms • this pain is precipitated (increased) by physical exertion • the pain is relieved by rest or a GTN spray.

32. We know from Mr W’s own reports that he had constricting pain and that the pain was relived via the use of his GTN spray. However, what the clinical records do show is that at the face to face assessment Mr W’s pain was not precipitated or caused by physical exertion. Therefore, we cannot say the Practice did not assess Mr W for anginal pain nor that he exhibited all of the expected symptoms as detailed in the NICE CG95 guidance.

33. It is pleasing to see the Practice undertook a comprehensive significant event analysis of this issue on the back of this complaint. It has taken steps to make reasonable improvements to its services, including taking further detail from telephone appointment patients and in pain triage.

34. Given we are unable to find any indication of failing in the actions in how the Practice treated Mr W, it is our decision to conclude our investigation here.

35. We hope that this decision provides some resolution for Miss W and her family, and they have our condolences.

36. It is important to acknowledge that where we have not identified any indications that something went wrong, it does not detract from the family’s experience, nor the impact this has had on them.

37. Complaints give us valuable insight into the organisations we investigate, and we recognise this has been an emotionally challenging process for Miss W and her family. We would like to thank Miss W for sharing the family's experience with us.

1. We have carefully considered Miss W’s complaint about the Practice. Our decision is that we see no indication that the Practice acted wrongly in this matter.

2. We understand that this may not be the outcome Miss W would like, and we hope the below statement details our thinking and assists her in understanding our position. It is clear from our investigation, Miss W cared deeply for her father. We offer our condolences for her loss.

3. Miss W complains regarding the conduct of the Practice in early May 2024. At the start of May, Mr W contacted the Practice via its online portal complaining of chest pain. He was not offered an appointment until the next day.

4. The next day Miss W attended the Practice with Mr W. The Practice diagnosed Mr W’s pain as a chest infection despite Mr W’s history of angina and sent Mr W away with antibiotics. Angina is a type of chest pain caused by the heart not getting enough blood.

5. Two days later Mr W sadly died of heart failure at his home. Miss W is of the opinion the Practice should have done more to treat her father when he first contacted the Practice at the start of May 2024.

6. Our decision is from assessing the clinical records provided by the Practice, and with no indication these records are incorrect. We compared these records to national guidance on the relevant matters. We cannot see any indication that the Practice acted incorrectly in how it treated Mr W at the start of May 2024. We will detail this decision below.